Exercise
Learn more about Long COVID, why it’s called Long COVID, its common symptoms and episodic nature, its impact on day-to-day life, safe Long COVID rehabilitation, and pacing.
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Video Transcript (Audio as Text)
Exercise
Exercise has been used therapeutically for as long as civilisations have recorded their activities and in Western medicine it has been connected to treatment, rehabilitation and recovery. Therapeutic exercise can provide global health benefits and is often viewed as having few downsides or risks. Research has shown that exercise improves health and functioning for many different conditions. However, many people also live with certain health conditions where inappropriately prescribed exercise worsens symptoms and health. So who might we marginalise or harm when claiming exercise is medicine for all?
First, we must understand exercise and how it is defined differently from physical activity. These two terms are often confused with one another and sometimes used interchangeably. Physical activity is any bodily movement produced by muscles that results in using energy, and in daily life can include working, sports, or household activities.
Exercise is defined as planned, structured, repetitive, and purposeful activity focused on improving or maintaining physical fitness. It can be aerobic, resistance, or exercises for specific conditions. Therapeutic exercise includes graded exercise therapy, which is a method that clinicians or healthcare providers can prescribe based on fixed incremental increases in physical activity or exercise.
Now we understand these terms, what do we already know about Long COVID and exercise in 2024?
Often, discussions about Long COVID and exercise result in debate, with strong views in all directions. Some people may simply presume exercise works for everybody. Some people with Long COVID have worsening symptoms for days, weeks, or longer after exercising, while others get better. There are people who raised alarms about graded exercise therapy and the harm it caused to people with ME/CFS, and want to stop the same mistakes from happening again.
What we do know, is that research shows us that people with Long COVID have physiological changes in the body including impairments in how muscles get and use oxygen, changes to how the heart, lungs, muscles and nervous system respond to exercise, damage to the linings of blood vessels, inability of the mitochondria (or powerhouses of cells) to work correctly, and there can also be the continued presence of viruses. Additionally, many people with Long COVID have post-exertional symptom exacerbation. These problems affect the way bodies work, with changes to the body’s energy system. Meaning these problems simply cannot be explained by normal exercise responses, deconditioning, or not moving enough. This may help explain why so many people living with Long COVID who have tried to keep active and exercise, have not managed to recover or get better over time but got worse because of exercise.
Learning the lessons from ME/CFS, and focusing on what is safe rehabilitation, continues to be so important. Post-exertional symptom exacerbation is a critical symptom that can prevent people from moving more, keeping active, and participating in life roles. It is this symptom that is a key consideration of who will not benefit from therapeutic exercise. The World Health Organization recommends avoiding therapeutic exercises in people with post-exertional symptom exacerbation, mirroring the NICE guidelines that recommend people with ME/CFS should not be offered any programmes based on deconditioning or exercise avoidance theories, including graded exercise therapy.
This is why so many Long COVID rehabilitation guidelines recommend pacing to balance activities with rest, and make it clear that any approach to physical activity or exercise must be guided by the presence and severity of symptoms, with consideration for the symptoms that can fluctuate or go up and down and available energy levels.
Prescribing fixed incremental increases in physical activity or exercise without these considerations shows a lack of understanding or experience in applying principles of exercise prescription, training, and programme design for any population, healthy or unwell. Graded exercise therapy is neither peronalised nor person-centred care. Equally, safe rehabilitation does not mean avoiding all activity, or not moving.
We may not yet have answers on the causes of Long COVID, and who with Long COVID improves or worsens from exercise. But we know from millions of people around the world sharing their lived experiences, that exercise and pushing through symptoms has made their Long COVID disability worse.
People with Long COVID want to feel better, do daily activities, and live a meaningful life. If people with Long COVID could move more, they would, and rarely do they need encouragement from healthcare professionals just to move a bit more, because they have probably already tried and suffered the setbacks or consequences.
If we have not solved Long COVID with the usual approaches to recovery, we will not cure Long COVID with the same thinking. Innovation and novel approaches can, and should, be co-produced with people living with Long COVID, to make advances together.
We hope that research can help us better understand what causes Long COVID to provide treatments that reduce symptoms and improve functioning. Until we have safe and effective treatments, let's not marginalise people with post-exertional symptom exacerbation by encouraging exercise. We can avoid harm.
Like all medicine, treatments must be individualised, safe and effective. If exercise is considered a medicine, then all who prescribe it must also understand when it is safe, what are the risks, what is an effective dosage, and when is it contra-indicated. A clear message from many with Long COVID is that exercise is not the right medicine.
This is the end of the Long COVID Video Series. Thank you for joining us.
Credits
This video was illustrated and edited by FisioCamera:
https://www.fisiocamera.it/ fisiocamera@gmail.com
The script was written and narrated by:
Darren Brown OBE, Physiotherapist, UK
This video received consultation by:
Lindsay Skipper, Long COVID Physio Peer Support Committee, Physiotherapist, UK
Prof Todd Davenport, Chair Long COVID Physio, Workwell Foundation and Department of Physical Therapy, University of the Pacific, Stockton, California, Physiotherapist, USA
Dr Kelly O'Brien, Long COVID Physio Research Committee, Professor at the Department of Physical Therapy and Co-Director of the Rehabilitation Science Research Network for COVID, University of Toronto, Physiotherapist, Canada
Prof Mark Faghy, Vice-Chair Long COVID Physio, Professor in Clinical Exercise Science University of Derby, Exercise Physiologist, UK
Dr David Putrino, Director of Rehabilitation Innovation for the Mount Sinai Health System, and Associate Professor of Rehabilitation and Human Performance at the Icahn School of Medicine at Mount Sinai, Physiotherapist, USA
Dr Jenny Setchell, Senior Researcher at The Institute for Urban Indigenous Health and Adjunct Senior research fellow at The University of Queensland, Physiotherapist, Australia
Dr Daisy Motta Santos, Long COVID Physio Education Committee, Exercise Physiologist, Brazil
Cathy Thomson, Long COVID Physio Advocacy Committee, Physiotherapist, UK
Scott Venkataram, Vice-Chair Long COVID Physio, Physiotherapist, USA
Daria Oller, Vice-Chair Long COVID Physio, Physiotherapist and Athletic Trainer, USA
Hanna Markkula, Long COVID Physio Education Committee, Physiotherapist, Finland
Francis McGuire, Long COVID Physio Disability and Safe Rehabilitation Committee, Physiotherapist, Switzerland
Jessica DeMars, Long COVID Physio Disability and Safe Rehabilitation Committee, Breathwell PT, Physiotherapist, Canada
Marcos Rodrigues, Long COVID Physio Equity Diversity and Belonging Co-Director, Faculty Lecturer Clinical Education, School of Physical and Occupational Therapy, McGill University, Physiotherapist, Canada
Etienne Ngeh, Long COVID Physio Equity Diversity and Belonging Co-Director, Founder of Research Organisation for Health Education and Rehabilitation-Cameroon (ROHER-CAM), Physiotherapist, Cameroon
This video was peer-reviewed by Long COVID Physio Leadership Team
Date Last Revised: 23rd July 2024